HomeMy WebLinkAboutSeptic Pumping Slip - 10 DEER MEADOW ROAD 2/20/2018 Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACHUSElls %'VSD
4x
System Pumping Record
Form 4 .�
DEP has provided this form for use by local Boards of Health. The System Pumpi ;4V s
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the //
computer,use L._��r_..._ ��....._ �'/9 {
only the tab key Address
to move your /� ,( ,�
cursor-do riot ..--. !_4 A ,tU�'�__.._ _ �._�__...,.,_.._..
use the return Cityfrown State Zip Code
key.
2. System Owner-
Name
Address(if different from location)
Cityfl"own State Lip Code
'retephone Number
B. Pumping Record
1. Date of Purnping / -: 2. Quantity Pumped: � 0-2) ._, ._..
DateGallons
3 Type-, of system: n Cesspools) _ Septic Tank Ll Tight Tank
[. ) Other(describe):
4. Effluent Tee Filter present? 0 Yes (_-1 No If yes, was it cleaned? FJ Yes [� No
Vii. ConditionofSystern:
6. System Pumped By:
Name vehicle License Number
Company
7. Location where contents were disposed:
_,_,... ..Lam. ......� _._--_.,-,......� _ ...�
Signature of Hauler pate
http:l/www.mass.gov/dep/water�/approvals forrxts.tttm#inspect
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